In the News: August 31–September 6

First Gene Therapy Approved by FDA

The FDA recently approved Kymriah, a Chimeric Antigen Receptor (CAR) T-cell therapy, to treat certain children and young adults (up to 25 years of age) with B-cell acute lymphoblastic leukemia. This approval makes Kymriah the first cell-based gene therapy approved in the US.

In January, the Sg2 Technology team highlighted CAR T-cell therapy as a key disrupter that has the potential to disrupt health care in the near-term. For more information, watch the Sg2 on-demand webinar: Disrupters to Watch in 2017 from minute14:11. The webinar also highlights 5 other key disrupters identified by Sg2’s Technology team.

Anthem to Roll Out Site-of-Care Restrictions for MRI and CT

Anthem is expanding its site-of-care restrictions for MRI and CT to 13 of its 14 states by March 2018. From July 1, 2017, Anthem has required hospitals in select states to submit precertification requests for MRIs and CT scans performed in hospital outpatient departments (HOPDs). These requests undergo a medical necessity review by AIM Specialty Health® and if deemed “NOT medically necessary for the member to receive the service in a hospital setting, the request for authorization will be denied as not medically necessary for that site of care.” This Anthem site-of-care policy notably resembles UnitedHealthcare’s site-of-service authorization for certain elective procedures that require prior authorization to be performed in a HOPD.

In many markets across the country, converging forces threaten to reduce provider systems to price-takers, particularly for high-volume outpatient services. See how progressive health systems are responding to pricing pressure in the Sg2 report: Pricing Strategy.

Sepsis Costs Medicare More Than Any Other Discharge

According to Modern Healthcare, sepsis was the most common and costly inpatient discharge for Medicare beneficiaries in 2015, with Medicare costs for these discharges totaling $6B, a $0.7B increase from 2014. The authors attribute this to a large increase in the number of sepsis discharges (82,761) but note that this may partly be an artifact of DRG coding.

Sg2 experts believe that increased recognition of this deadly disease will lead to focused cost-reduction efforts in the coming years. To learn more, read the Sg2 report: Medicine Forecast 2017, where page 6 summarizes the latest Impact of Change® forecast and highlights key trends in septicemia.

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As of February 11, 2016, Vizient, Inc. has completed its purchase of MedAssets Sg2 and spend and clinical resource management segments from Pamplona Capital Management, LLC. MedAssets revenue cycle business will continue to operate as a wholly-owned subsidiary of Pamplona Capital Management LLP.